New Patient Intake Form
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone Number
*
-
Area Code
Phone Number
Home Phone Number
-
Area Code
Phone Number
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Drug Allergies
*
No Known Drug Allergies
Aspirin
Cephalosporins
Codeine
Demerol
Erythromycin/ Azithromycin
Sulfa Drugs
Penicillins
Quinolones
Other
Specific Health Conditions
*
None Known
Asthma/ Respiratory Disease
Cancer
Congestive Heart Failure
Diabetes
Epilepsy
High Blood Pressure
Kidney Disease/ Disorder
Liver Disorder
Ulcers
Other
Please List ALL Medications Currently Taking, including Over the Counter:
How Did You Learn About Prosperity Drug?
Do you want your prescriptions transferred here from another pharmacy? If so, indicate where your prescriptions currently are below:
What is your current pharmacy's phone number?
Child Resistant Bottle Preference:
*
Child Resistant Caps/ Lids
Easy Off Caps/ Lids
I give permission to have my prescriptions dispensed in non-child resistant containers and will assume all responsibility for such containers:
*
YES, I AGREE
Please send us a picture of your insurance card:
I certify that all information on this form is true, accurate, and complete. I agree that the medical information on this form may be released to medical personnel working on behalf of the patient. I understand that only prescriptions filled by pharmacists at this location will be checked against the information on this form.
*
YES, I AGREE
Signature
*
I certify that all information on this form is true, accurate, and complete. I agree that the medical information on this form may be released to medical personel working on behalf of the patient. I understand that onlyh prescriptions filled by pharmacists at this location will be checked against the information on this form.
Submit
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